Disease

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In 1987 I started my psychiatry residency. Since then, they have changed the Diagnostic and Statistic Manual three times and it still does not seem to be keeping up with how fast the world is changing around me.

I one saw lots of “lethargic” depressions. Slow and sleepy “ain’t got no energy” depressions. “I feel like a human blob” kind of depressions.

Now most of them turn out to be Type II (“adult onset”) sugar diabetes or the thyroid just stopped working for some creative reason. Read more on Then and Now…

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A fair amount of psychiatric illnesses have a genetic component.

Being formally “diagnosed” by a doctor does not make them official.

It is hard to tell when a woman says “my mother was probably depressed and anxious” what was going on. There may be a genetic component. Read more on Family Histories…

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There are a certain number of patients who come to me suffering from autoimmune disease. Yes, more than one.

Sometimes Lupus or Celiac disease or rheumatoid arthritis or such.

Often they get through life dragging along with them unidentified articular pains, which are themselves probably an unidentified autoimmune illness. Read more on Depression As Auto-immune Disease…

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His mother had been seeing me and they had signed mutual releases. Mother wanted me to see him as soon as possible, because he was “nervous and unable to sit still at all.”

When he came, he denied a “nervousness” which his mother thought looked like “attention deficit disorder.”

I can’t treat what people don’t think they have.

He described problems with his girlfriend and his mother, since his mother had told him he could not go to a party in the home of his girlfriend’s family on the bad side of town, “where they would just as soon shoot you in the street as say ‘hello.'”

He sounded like he had pretty routine mother-and-girlfriend problems.

She contacted me on the weekend, worrying about him frequenting strip clubs, something I had not asked about and he had not told me about. Sometimes, she said he became so angry she physically feared him.

Their two narratives were simply inconsistent. I drew the line at her feeling scared of him physically.

I told her about “tough love,” and I told her if that happened again, to call the cops.

My husband reminded me of the ultimate authority in my profession — Hugh Laurie as “Dr. House” — who repeatedly said on television in public for all the world to hear, “Patients lie.”

Which one of them? Maybe both of them. I told her what I had told them; and would indeed, tell anybody who gave me the opportunity. I can try a session with the two of them together and help to resolve things, but I could not promise that it would resolve things. I would try. I always try as hard as I can to do the best that I can.

She said she knew this to be true.

I had told him and also told his mother on the phone, that the hardest thing a young man (or a young woman) ever had to do in his (her) life was establishing themselves as an individual distinct from parents. This usually meant a period of confusion before resolution. There may be (and there was) some confusion about vocational direction, too.

One can only press forward. The ability to communicate openly is precious, and irreplaceable. 

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After less than a week in second year medical school, I had survived the elimination contest exam, coming in 38th of the 650 examinees. Thus I earned my place in the amphitheater that held only 110 people, including the spare chairs wedged into the stairwell.

The cornerstone on the building — the original cornerstone — said clearly, “1568.” It was not a museum, but a living medical school building. I suppose some monks had practiced here in the building at the outset when medicines were mostly tinctures, maybe marijuana if they were lucky. 
In the ancient dissection room, were four slate tables for cadavers. They were not easy to obtain, for it was said very few wanted their bodies dissected after death. The slate tables had rivulets carefully carved into them. The floor around the tables had buckets to catch various bodily fluids.

During my dissection, the master who supervised pointed a finger at me and the three other students at our table. Tradition said that “Sylvius, of the “Sylvian Fissure” had dissected at that very table. Sylvius,” meaning “from the woods” in Latin is “DuBois.” a common name in French. This fissure, that separates the frontal and temporal lobes, is so named in all the language in which medical terminology is known to me. He is sometimes claimed by Germany and sometimes by Holland.

I have looked into it enough to know he had a couple of “teaching voyages” around Europe, and his dates of activity would have made his presence in my dissection room very possible, indeed. The first day I was in this amphitheater, my physiology professor, from an ancient French family which alleged lineage dating back to 18th century pre-revolutionary French nobility, sidled up to my table and rapped on it, as if to focus his attention on me — before starting his lecture. “Mademoiselle,” he said, “you should be ashamed of yourself. You have taken a seat in this class away from a deserving Frenchman, who could earn a salary and raise a family.” The amphitheater could not have been more silent since 1568. I heard my own voice tremble. “With all due respect, Monsieur, I am here according to the Napoleonic Code of 1802, which opened the Universities of France to people coming from all nations who are capable of speaking the French language, so that they return with French culture to their nations of origin. I am pleased to be so honored. Vive la France!”

Pretty much any time you say “Vive la France!” in am amphitheater of students it is fairly certain that the whole amphitheater will end up cheering and shouting “Vive la France,” which they did. My poor professor was silenced, and shook his head. Nobody else said anything derogatory about my origins to me for the remainder of my education.

Later that week was my first lecture in neuroanatomy. I had loved the brain and its mystery and majesty long before starting the study of medicine. In first year medicine we were focused primarily on learning the limbs, with the brain and the head, neck thorax, and abdomen saved for the second year. Strangely I cannot remember the professor’s name. He was ancient and had to be helped up to the master’s lectern, One of the students told me he had been teaching before World War II. He had an essential tremor — head and neck, and sometimes the whole of his body. His voice seemed feeble, even with the microphone of the lectern. He wore a vest and trousers beneath his white coat.

“Mesdames, Mesdemoiselles, Messieurs … To me, falls the responsibility of teaching you the brain. When I address you, I speak to your brain. Assiduously studied, for hundreds of years, we knew little about it before World War I. The brave “poilus,” the French soldiers who protected this great nation in WWI , gave their lives — and all too often, gave us their brains. From knowing what part of their brain was missing and what they were unable to do in their twilight of their young lives, we learned what part of the brain did what. From this, we have evolved into a people whose knowledge of the brain we share with the world.”

He stared at me, and I felt as if his eyes burned holes in my flesh. “This organ is so complex, I do not teach with the pathologists’ photographs or drawings, but with simple circles of colored chalk to show you their bunches and bundles in cross-section. Learn them well, for they were learned from people’s lives and memories.” The other students told me later, when I talked to them that they were suppressing giggles. Me, I was suppressing tears. I have heard many complaints about nearly everything about medical education. But I have never heard anybody tell me about a deeper contact with being part of the research and education tradition than I did at that moment.

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Medical school in France was very cheap and open to anyone who wanted to enroll — at least for the first year. Only those who scored highest on year-end exams were allowed to continue to 2nd year.

Over 600 hopeful students enrolled that first year — but I worked extra hard and placed 38th. Only about a hundred were admitted. I was in!

Soon after I passed the “elimination contest” that was meant to let those of us who had scored best (and were allegedly the smartest) continue with the business of medical school. We had to get down to the business of learning things that we would need to function as doctors. Read more on My Training As A French Country Doctor…

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Mature female patient: “So you’re Dr. Goldstein! Wow , you’re dressed so elegant! I mean I feel really self-conscious! I just threw on a t-shirt and shorts…”

Dr. G: “Don’t worry, darling. You got it right — I’m the one who’s supposed to get dressed up. Now, you’re not going to think much of me.” Read more on Dr. Estelle gets a new patient…smiling, laughing…

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Often they are working women.

But people with no employment and no financial responsibility are not immune.

It is surely the illness of our time for everyone complains of it sometimes as if it has a specific treatment and they think I can change the deficient choices they made several years ago in their lives to make things fine and dandy with an instant prescription.  W.H. Auden wrote the (long) poem ” Age of Anxiety” in 1947 or so describing man’s attempt to find meaning and substance in an industrialized world. Read more on All The Stressed Out People…

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It was a particularly beloved patient who asked me if I had any advice about improving creativity. She believed, as many people do, that it is a side effect of treating (even a relatively minor form) of bipolar illness. A lot of research back in the days of lithium, one of the first really robust treatments for bipolar illness, strongly suggested it just wasn’t so. Read more on Will Bipolar Treatment Kill Creativity?…

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Although it theoretically is marginally ethical, I frequently find myself performing a rudimentary psychoanalysis of people I have never met.

I usually find it helps to explain a life or an origin of suffering, or some kind of human empathy, and can bring peace or closure to the folks who come into my office — or the folks who are my friends.

It was a really good friend who told me on the phone today, “I thought of you this past week. My Uncle Ed died.” Read more on Uncle Ed — The War Hero…